Synopsis
Refer appropriate liver disease early, understand UK selection and graft complications, and protect recipients through precise immunosuppression, infection and long-term risk management.
- Early transplant referral creates time to assess reversibility, frailty, infection, cancer, cardiopulmonary risk, adherence and the patient's goals before crisis occurs.
- UK listing and allocation follow current NHSBT policies; UKELD, super-urgent status and disease-specific criteria support but do not replace transplant-centre judgement.
- Indications include decompensated chronic liver disease, acute liver failure, selected HCC and certain metabolic, cholestatic or symptom-dominant disorders.
- Immediate graft threats include primary non-function, hepatic-artery thrombosis, portal or hepatic venous problems, biliary leak or obstruction, infection and acute rejection.
- A normal or mildly abnormal liver panel cannot exclude a serious vascular or biliary complication when symptoms or Doppler findings are concerning.
- Tacrolimus exposure is managed by the transplant team using trough concentrations, formulation, time after transplant, graft function, renal function and interacting medicines.
- Macrolides, azole antifungals, rifamycins, some anticonvulsants, grapefruit and St John's wort can cause dangerous tacrolimus changes; check before prescribing.
- Long-term care addresses kidney disease, hypertension, diabetes, dyslipidaemia, bone loss, infection, skin and other cancers, vaccination, recurrence and psychological health.
Key red flags
Coagulopathy with encephalopathy in a patient without known cirrhosis can deteriorate within hours. Contact a transplant centre early while pursuing cause-specific emergency management.
Rising aminotransferases, lactate, INR or bilirubin, haemodynamic instability, hypoglycaemia and low bile output after surgery require coordinated Doppler, laboratory and surgical assessment.
Fever may be muted; rigors, lethargy, cough, diarrhoea, urinary symptoms, rash or graft discomfort can represent bacterial, viral, fungal or opportunistic infection.
Investigation priorities
Define liver prognosis, comorbidity, technical feasibility and expected net transplant benefit.
Management branches
Liver disease has decompensated, progressed despite treatment, produced qualifying HCC or caused acute liver failure.
- Contact regional hepatology or the transplant centre early, supplying diagnosis, decompensation episodes, current physiology, infection status, renal trajectory, imaging and relevant alcohol or substance history.
- Optimise nutrition, frailty, ascites, encephalopathy, infection control and disease-specific treatment while assessment proceeds, avoiding a passive wait for a score to cross a threshold.
- Use current NHSBT selection policy and centre review for standard, non-standard and super-urgent indications, and give the patient balanced information about waiting-list, donor and post-transplant risks.
The recipient is clinically stable after the early transplant period and routine care is shared locally.
- Maintain an up-to-date medication and interaction record, planned trough and renal monitoring, and a clear process for contacting the transplant pharmacist before new prescriptions or supplements.
- Review blood pressure, diabetes, lipids, kidney function, bone health, weight, vaccination, skin protection and standard cancer screening, tailoring frequency to regimen and risk.